Virginia Department for the Blind and Vision Impaired

BVI 702070002 (11/88) EYE EXAM REPORT VIRGINIA DEPARTMENT FOR THE BLIND AND VISION IMPAIRED

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PATIENT INFORMATION:

Name: Telephone: ( ) - Address: Date of Birth: City/State/Zip Code: Social Sec. No.: - - Sex: Race: Parent/Guardian (if appropriate): EYE EXAMINATION INFORMATION: OD OS OU Distant Acuity Without Correction Distant Acuity With Correction Near Acuity Without Correction Near Acuity With Correction Field Diameter (Complete reverse side)

Primary Age at Secondary Age at Impairment Onset Etiology Impairment Onset Etiology OD OS

PROGNOSIS (check one): Stable Deteriorating Can Improve Uncertain DESCRIPTION: GLASSES (check one): Constantly Near Distance Visual Tasks New Prescription No Change

SPHERE CYLINDER AXIS PRISM OD OS ADD

RECOMMENDATIONS: Indicate needed treatment(s) or surgical procedures and their C.P.T. code(s):

Check One: Outpatient clinic/office Outpatient Hospital Inpatient Hospital Address: Low Vision Exam: Yes No Re-Exam: Yes No When EXAMINIER:

Examiner’s Signature Date of Exam Date Signed DBVI AUTHORITY USE ONLY: OPH MD OD Legally Blind- Yes No Examiner’s Name (Please Print)

Address DBVI AUTHORITY:

City / State / Zip Code Date

of 2 BVI 702070002 (11/88) EYE EXAM REPORT VIRGINIA DEPARTMENT FOR THE BLIND AND VISION IMPAIRED

INSTRUCTIONS: Determine the peripheral visual field of each eye on a standard perimeter, using a 3 mm white test object, or a Goldman III-4e target. Record the Field at its widest diameter on this chart.

THE VIRGINIA DEPARTMENT FOR THE BLIND AND VISION IMPAIRED provides services to legally blind persons of all ages throughout Virginia, as well as to some persons not legally blind but whose visual problems are progressive or of such magnitude that the specialized services of the Department are needed to assist them to achieve their maximum potentials. All such persons should be referred to the Agency for evaluation for services.

The Code of Virginia Section 63.1-71 directs the Virginia Department for Blind and Vision Impaired to: “prepare and maintain a complete REGISTER OF THE BLIND in the State, which shall describe the condition, case of blindness, capacity for educational and industrial training of each, and such other facts as the Department deems of value. Each physician, optometrist, or other person who, upon examination of the eyes of any person, determines that such person is a blind person as defined in Section 63.1-142, shall immediately report the name and address of such person to the Department.”

The Code of Virginia Section 63.1-142 states, “blind person means a person having not better than 20/200 central visual acuity in the better eye measured at twenty feet with correcting lenses; or having visual acuity greater than 20/200 but with the widest diameter of the visual field in the better eye subtending an angle of no greater than 20 degrees measured at a distance of 33 centimeters using a 3 millimeter white test object, or a Goldman III-4e target, or other equivalent equipment. Such blindness shall be certified by a duly licensed physician or optometrist.”